IMPROVING THE PREOPERATIVE ASSESSMENT OF VARICOSE VEINS
 Singh S, Lees TA, Donlon M, et al.
Br J Surg 1997; 84; 801-802

ABSTRACT AND COMMENTARY BY:
Nicos Labropoulos, M.D.
Assistant Professor of Surgery
Loyola University Medical Center

A total of 71 limbs in 49 patients with primary varicose veins were examined by three surgeons using three different techniques. The first used clinical examination with tourniquet testing alone, the second used a hand-held Doppler, and the third used a color-flow duplex scanner. According to the protocol, it was required for the surgeons to identify which saphenous vein was involved, to determine if saphenous junctional reflux was present, and finally to chose one of the following procedures: 1) saphenofemoral ligation with stripping and avulsion, 2) saphenofemoral junction ligation and avulsion, 3) saphenofemoral ligation, stripping, saphenopopliteal ligation and avulsion, or 4) avulsion or sclerotherapy (if no evidence of saphenofemoral or saphenopopliteal incompetence). It was found that inappropriate surgery would have been performed in 14 limbs based on clinical examination alone and in 9 with the addition of hand-held Doppler.

COMMENTARY

The authors have challenged the traditional clinical examination with tourniquet testing and hand-held Doppler by demonstrating that approximately 10% of patients would have had inappropriate varicose vein surgery as demonstrated on color-flow duplex scanning. With the advent of new technology, the treatment of varicose veins is being refined and surgery can be targeted to appropriate places. However, as the authors point out, the cost of a duplex ultrasound examination is not insignificant and, in the absence of a randomized prospective study, its routine use may not be justified.

Although in general I agree with the authors, I would like to stress the importance of using color-flow duplex scanning in the preoperative assessment. The venous system is very complex with many anatomical variations. The area with the most clinically important variations is the popliteal fossa. The lesser saphenous vein terminates within 5 cm above the popliteal skin crease in about 60% of cases. It often unites the femoral vein in the thigh, or the greater saphenous vein at mid thigh and above, or the medial gastrocnemius vein at the level of the skin crease. A few other patterns and a combination of any of the above may coexist in one limb. Other veins that may be involved in this area are tributaries arising from lower thigh posterior and posterolateral perforating veins, the vein of the popliteal fossa, and veins from the sciatic nerve.

In the greater saphenous vein distribution, many different patterns of reflux have been described such as saphenous reflux in the absence of saphenofemoral junction incompetence, isolated reflux in the above- or below-knee segment of the greater saphenous vein, or incompetence involving the saphenous tributaries alone. Furthermore, color-flow duplex scanning is accurate in the detection of incompetent perforating veins while clinical examination has a sensitivity of approximately 60%. Finally, incidental findings such as hematoma, cysts, tumors, and aneurysms that may or may not be related to the patient's symptoms can be identified during imaging. 6916b




VENO-LYMPHATISCHE ANGIODYSPLASIE ALS URSACHE EINER INGUINALEN REZIDIVVARIKOSE (Veno-lymphatic Angiodysplasia as a Cause of Inguinal Recurrence)
 Kohler A, Dirsch I, Brunner U
VASA 1997; 26:52-54

ABSTRACT AND COMMENTARY BY:
Dr. med. Reinhard H. Fischer
St. Gallen, Switzerland

The authors describe two cases of recurrent varices in the groin in connection with a local lymphovenous dysplasia. Histologic examination revealed a vein penetrating a lymph node. The venous wall showed reticular fibrosis and focal myofibrosis of the intima. The vein was surrounded by lymphatic tissue forming secondary follicles, and there was a subcapsular sinus. The capsule was formed by collagen fibers. The authors assume that the cause for the appearance of the vein was angioneogenesis in connection with dysplasia which in turn was the cause of recurrent varicosities from the saphenous stump. Proof of this was not possible.

In 1990, Leu described five such cases.1 Four were observed at the primary operation and one at the operation of a recurrence. In these five cases as well as the two cases presented here, there was no histopathologic clue as to whether the primary varicosis or the recurrence was caused by stenosis of the greater saphenous vein by the constricting dysplastic lymph node or by angiodysplastic angioneogenesis.

COMMENTARY

The Brunner group2 has published a widely accepted classification of varicose vein recurrence in the groin (Figure 1).



1. Type I: A long saphenous stump left at the primary operation.
2. Type II: A double saphenous vein.
3. Type III: A side branch flowing directly from the common femoral vein.
4. Type IV: A newly formed saphenous-like vein filled by multiple small collaterals.
5. Type V: A perforating vein from the superficial or deep femoral vein.

In addition, Brunner calls attention to an angiodysplastic type. The two cases presented here would be a subgroup of the latter.

In my practice, I see the percentage of inguinal recurrences after correct saphenofemoral ligation definitely increasing when compared to recurrences after faulty ligation. Therefore, topics like angioneogenesis as a possible cause for recurrence after correct ligation will assume greater importance. The type of primary or recurrent saphenous insufficiency described here is rare but not extremely so. I have seen a few cases suggesting this pathology at the time of operation or at histologic examination. For future discussions, it may be worthwhile to keep this possible etiology of recurrences in mind. 6920b

REFERENCES

1. Pouliadis GP, Th¸rlemann A. Zur Vermeidung von Rezidivvarikosen ab Leiste. In: Brunner U (Hrsg) Die Lieste. Reihe Aktuelle Probleme in der Angiologic 38. Verlag Hans Huber Bern 11979, pp 172.81.

2. Leu HJ. A rare case of angiodysplasia: Penetration of inguinal lymph nodes in large superficial leg veins. Virchow Archiv A Pathol Anat 1990; 417:188-96.




LESSONS LEARNED FROM STUDY OF RECURRENT VARICOSE VEINS
 John J. Bergan, M.D.
La Jolla, California


The abstract and commentary by Reinhard Fischer calls attention to a cause of recurrent varicose veins. This is the phenomenon of neoangiogenesis. In the March 1997 issue of Venous Digest , Simon Darke of Dorset, England abstracted a publication in which color-coded duplex ultrasound was used to investigate the results of a prospective randomized trial comparing simple saphenofemoral ligation with greater saphenous vein stripping. In that study, once again just over 50% of cases of recurrent varicose veins were caused by neovascularization from the femoral vein.1

In contrast, in an ultrasound analysis of recurrent varicose veins by Ruckley's group, neovascularization was encountered in only five limbs of 128 studied. Ruckley's classification has been found to be useful as it divides recurrent varicose veins into a type I which requires reoperation at the groin and a type II which consists largely of two kinds of outward flow reentering a retained saphenous vein in the thigh. In the latter, the groin need not be explored but the residual saphenous vein can be removed to cure the recurrent varicosities.2

A disappointing cause of recurrent varicose veins was reported recently at the London Association of Surgeons meeting. In this study, 18 limbs were operated upon for recurrent varicosities of the groin. In two, incompetent connections had not been interrupted between the common femoral vein and the recurrent varicose veins in the thigh. In one, the saphenofemoral junction was intact even though this had been operated upon. In four limbs with previous saphenofemoral ligation, the existing saphenofemoral junction was present in three after the surgery.

When surgical trainees were compared to staff, the authors concluded that "the implication of this is that trainees perform the surgery less adequately than consultants."3

Perrin recently commented on Ruckley's classification and proposed a new one of his own in which the subsequent correction of recurrent varicosities would be implied by the classification itself. In this presentation, he suggested an international meeting in order to formulate a classification which could be adopted universally.4

An underlying theme in all interest in recurrent varicose veins is that persistence of the saphenous vein in the thigh is a target for retrograde flow. The retrograde flow may come from a network of veins left in the groin following proximal ligation or from outward flow from thigh perforating veins. In either case, the recurrent varicosities could have been avoided by groin-to-knee saphenous vein stripping.

Therefore, lessons learned include: 1) the necessity for trained individuals to perform the saphenofemoral exploration, 2) the need for complete eradication of the possible network of veins which can cause recurrence, and 3) need to remove the greater saphenous vein from groin to knee.

In a well-conducted study by Myers in Melbourne, it was said that "recurrence after ligation alone was usually due to a single large connection passing to the intact long saphenous vein or its major tributaries."5 Furthermore, the Australian group said, "recurrence after ligation and stripping was from multiple smaller connections passing to scattered tributaries... there was a considerable proportion with a large single connection to the large saphenous vein or its major tributaries after stripping, suggesting that the initial technique was probably inadequate.

Finally, as Fischer points out in his commentary above, the subject of angioneogenesis may be important in the future especially if technical errors diminish and more complete operations remove the saphenous vein in the thigh. This is an important topic which demands further clinical research. 6920wb

REFERENCES

1. Jones J, Braithwaite BD, Selwyn D, et al. Neovascularization is the principal cause of varicose vein recurrence: Results of a randomized trial of stripping the long saphenous vein. Eur J Vasc Endovasc Surg 1996; 12:442-45.

2. Stonebridge PA, Chalmers N, Beggs I, Bradbury AW, Ruckley CV. Recurrent varicose veins: A varicographic analysis leading to a new practical classification. Br J Surg 1995; 82:60-62.

3. Lees T, Singh S, Beard J, Spencer P, Rigby C. Prospective audit of surgery for varicose veins. Br J Surg 1997; 84:44-46.

4. Perrin M. Comment classer les recidives variqueuses apres traitement chirurgical? PhlÈbologie 1996; 49:453-60

5. Myers KA, Zeng GH, Ziegenbein RW, Matthews PG. Duplex ultrasound scanning for chronic venous disease: Recurrent varicose veins in the thigh after surgery to the long saphenous vein. Phlebology 1996; 11:125-31.




THE INFLUENCE OF DRESSINGS ON VENOUS ULCER HEALING: A RANDOMIZED TRIAL
 Stacy MC, Jopp-McKay P, Rashid SE, et al.
J Endovasc Surg 1997; 13:174-79

ABSTRACT AND COMMENTARY BY:
Warner P. Bundens, M.D., M.S.
Department of Surgery
University of California San Diego
Director, CircAid Medical Products, Inc.

This group from Western Australia reports the results of a prospective randomized trial of three different dressings/bandages used to treat venous ulcers. A total of 133 ulcerated limbs were treated with either a zinc oxide-impregnated gauze bandage (essentially an Unna boot), a zinc oxide-impregnated stockinette, or a calcium alginate dressing. All ulcers were then covered by two minimal-stretch bandages (Elastocrepe) which were held in place with a stockinette (Tubigrip). Healing was measured as time to complete healing of the ulcer. Those that did not heal in nine months were reported as treatment failures.

Patient characteristics did not differ significantly between groups on entry into the study as to sex, age, ulcer size, or duration. There was a difference in the proportion of patients with only superficial disease with the alginate group having a significantly higher percentage (54%). However, photoplethysmographic refilling time with and without tourniquet was used to make this determination, and the accuracy of such methodology has been questioned.1,2 Interestingly, interface pressure between the dressings and the skin was also measured at the time of application at three levels on the patient limbs and none produced a "graduated" compression.

The authors found that time to complete healing was significantly improved by a small initial ulcer size, the ulcer being on the right side, and the use of Unna boot-type dressing. A total of 64% of ulcers in the Unna boot group had completely healed by 12 weeks with 85% at 36 weeks. Both the zinc oxide/stockinette group and the alginate group healed approximately 45% at 12 weeks and 70% at 36 weeks. In their discussion, the authors point out the implication of the benefits of the non-elastic Unna-type dressing over the more elastic treatment modalities in improving venous return with ambulation as well as the relative noncontributory effects of the zinc oxide paste and topical alginate. The Unna-type dressing was also significantly better tolerated with 86% of this group completing the study versus 66% and 59% of the stockinette and alginate groups, respectively.

COMMENTARY

There are relatively few good venous ulcer healing studies in the literature,3 thus this well-done investigation is most welcome. One can accept the data as to the relative efficacy and patient acceptance of the three treatment systems evaluated. The paper does, however, raise questions as to the value of graduated compression though the authors point out that interface pressures were only measured at the time of initial application of the dressings. The finding of significantly slower healing in left leg is also interesting but not discussed. While it is well known that because of pelvic vascular anatomy, venous hemodynamics in the left limb may be slightly different than the right and occasionally affected (May-Thurner syndrome), this is the first paper I am aware of reporting a significant influence of side on healing rate. This could be the result of a type I statistical error or the first report of an interesting finding. 6922b

REFERENCES

1. Raju S, Fredericks. Evaluation of methods for detecting venous reflux. Perspectives in venous insufficiency. Arch Surg 1990; 125:1463-67.

2. Bays RA, Healy RA, Atnip RG, Neumyer M, Thiele BL. Validation of air plethysmography, photoplethysmography, and duplex ultrasonography in the evaluation of severe stasis. J Vasc Surg 1994; 20:721-27.

3. Goldman MP, Fronek A. Consensus paper on venous leg ulcer. J Dermatol Surg Oncol 1992; 18:592-602.




IS 'CHIVA' ONLY A MEDITERRANEAN TREATMENT OF VARICOSE VEINS?
 Agus GB, Bavera P, Mondani P.
Scope Phlebol Lymphol 1997; 4:9-13

COMMENTARY BY:
John J. Bergan, M.D.
Professor of Surgery
Loma Linda University Medical Center
Clinical Professor of Surgery
University of California, San Diego

Many interested investigators have explored vein-saving techniques in treating varicose veins. These investigators have explored external valvuloplasty of the saphenofemoral junction, banding the proximal portion of the greater saphenous vein and a Conservative Hemodynamic treatment of Incompetent and varicose Veins in Ambulatory patients (CHIVA).

This technique was introduced by J.C. Franceschi in 1988 and proposes reduction in intramural pressure since Franceschi thought this was the main cause of venous dilation. This is accomplished by abolishing identified sites of reflux in the superficial circulation and preserving the use of perforating veins as a means of blood reentry into deep veins. The CHIVA technique requires a complicated preoperative investigation to identify reentry perforating veins. Naturally, such an examination is subject to error, not only because of the great number of perforators but also due to the difficulty of verifying whether the vein is functionally competent or incompetent. Even duplex color-flow imaging does not clarify this completely.

Theoretically, the strategy of the CHIVA technique applies hemodynamic principles of column pressure fractionation, venous shunt disconnection, and preservation of venous drainage. The incompetent venous axes are tended to be interrupted at least in the upper one-third of the thigh and the upper one-third of the leg at sites which would not compromise drainage such as below a drainage collateral vessel or below a perforating vessel. A full description of ancillary procedures is beyond the scope of this abstract.

Although it has been said that more than 10,000 limbs have been operated upon using the CHIVA technique, a review of the literature has shown a few reports, the majority from Italy, a few from France, and only one from Spain. A correct analysis of the results is not easy but one thing is certain - the followup results have never gone beyond three years. Another fact is that the technique leads to a great number of complications such as superficial thrombophlebitis and the incidence of this complication varies from 3 to 20%.

Professor Agus of Milan says, "Franceschi's technique, CHIVA, benefitted initially from an enthusiastic consensus, often without criticism...and received...in some countries of the Mediterranean area, a wide public acceptance." He continues saying, "CHIVA seems to be an operation with very few indications because of conceptual... difficulties." He summarizes saying that it might be suitable for patients who are young and those who are able to avoid standing or sitting but is inappropriate for large varices and in patients whose occupation necessitates standing or sitting for long periods of time. His most interesting statement is a quotation from Alexis Carrel who gained the Nobel Prize for Medicine in 1912. Carrel said, "Little observation and much reasoning lead to error; much observation and little reasoning lead to truth." 6711b




DAS SOGENANNTE "ECONOMY CLASS" SYNDROME ODER DIE REISE-THROMBOSE (The So-Called "Economy Class" Syndrome or Traveler's Thrombosis)
 Nissen P.
VASA 1997; 26:239-46

ABSTRACT AND COMMENTARY BY:
John J. Bergan, MD, FACS
Professor of Surgery
Loma Linda University Medical Center
Loma Linda, California
Clinical Professor of Surgery
University of California, San Diego
San Diego, California

Thrombosis and pulmonary embolism associated with air travel is known as the "economy-class syndrome." However, thromboembolism is observed in other means of transportation as well. It can be generally described as "traveler's thrombosis." Our own observations include five patients with thromboembolic disease which occurred after long-distance travel.

Considering the large number of travelers, the reported incidence of associated thromboembolic disease seems to be remarkably low. Currently, there is no epidemiologic evidence which relates travel and thromboembolic disease. On the other hand, retrospective analysis of patients who manifest signs of thromboembolic disease of any origin indicates an incidence of approximately 5% related to transportation as a possible etiologic agent. Certainly, when one refers to the literature, the risk of traveler's thrombosis may be regarded as being quite low. Preventive or prophylactic action during long-distance travel should be taken into consideration in patients with high risk of thromboembolism.

COMMENTARY

Air travel and especially long-distance air travel continues to increase. Therefore, the manifestations of venous thromboembolic disease manifest at destination continues to be important. Now that the etiology of coagulopathy can be determined in as many as 50% of patients with thromboembolic disease, a large number of patients will learn of their occult coagulopathy. Certainly, those individuals should take energetic steps towards prophylaxis of venous thrombosis before long-distance air travel just as they would before a surgical intervention. Although the reporting of cases of traveler's thrombosis does not contribute any new scientific information, it continues to keep us alert to the fact that traveler's thrombosis occurs and that individuals with identified coagulopathy should take prophylactic measures. 6754b




THE ORIGIN OF LOWER EXTREMITY DEEP VEIN THROMBI IN ACUTE VENOUS THROMBOSIS
 Hill SI, Holtzman GI, Martin D, et. al.
Am J Surg 1997; 173:485-90

ABSTRACT AND COMMENTARY BY:
Joseph A. Caprini, MD, MS, FACS, RVT
Director of Research, Department of Surgery
Evanston Hospital
Evanston, Illinois

The purpose of this study was to determine the pattern distribution and different types of thrombi in patients screened in the vascular laboratory for venous problems using duplex ultrasonography. The study was prompted by the established belief that most leg deep venous thrombosis (DVT) begins in the calf and propagates proximally. A retrospective five-year review of 3,585 duplex scans performed on 2,654 patients suspected of having DVT was done. Demographic data, associated diseases, and all thromboses in either extremity were charted. The location of the thrombosis, the anatomical segment in which they were located, and the presence of a thrombosis in the contiguous segments, different segments, and different extremities were recorded for each patient. The patients studied (18% female and 32% male) had a mean age of 59.5 years. A total of 461 patients representing 17% of the total group were found to have a DVT and form the subject of this paper.

In the positive group, 41% were male and 59% were female with an average age of 53.4 years. In the 461 scans, thrombi were present in 854 locations, equally divided among the left and right lower extremities. The distribution of 854 thromboses among 12 possible locations (six in either leg) included: 16% iliofemoral, 13% common femoral, 19% superficial femoral, 18% popliteal vein, 24% calf veins, and 11% superficial veins. Further analysis showed that 19% of the 854 thromboses occurred bilaterally with 52% extending across two or more contiguous segments, 34% isolated thrombosis, 7.8% multiple non-contiguous thrombosis, and 5.6% bilateral thromboses in different locations. Overall more patients had thrombosis in the calf than any other location, although a majority (57%) had DVT without calf involvement.

The mean age of patients with a contiguous thrombosis was between 4.3 and 13.4 years greater than those with an isolated thrombosis. The mean age of those with bilateral thrombosis at different locations was between 5.5 and 24.3 years greater than those with a single isolated thrombosis. A total of 59% did not not have a comorbid condition. In 41% with coexisting disease, 15% had cancer, 21% had a severe medical illness, and 3% had a recent surgical procedure. Coexistent disease was present in a statistically significant percentage of patients referred for duplex scans. Seventy-nine percent (79%) of those patients referred with cancer had thrombosis. Sixty percent (60%) of patients with a myocardial infarction had positive scans, and thrombi were seen in 39% of those referred postoperatively. The authors also found a higher probability of an inpatient having a DVT than an outpatient (p > 0.001).

Nine symptoms were evaluated and compared with the location pattern of thrombosis. These included pain, edema, dyspnea, history of DVT, bilateral edema, cellulitis, postoperative state, trauma, and miscellaneous conditions. Patients presenting with edema were much more likely to have contiguous (62%) rather than isolated (25%) thrombosis. Bilateral edema was seen in only 6% of the total thrombosis group but was found with significantly higher frequency in those with bilateral thrombosis. None of the other symptom complexes were associated with statistically significant trends.

The authors conclude that by using duplex ultrasonography, they can accurately evaluate, study, and diagnose patients at all levels of thrombotic involvement from asymptomatic to phlegmasia cerulea dolens. The pattern and distribution of thrombi can be determined utilizing this technique which allows anatomical segment classification. Their findings indicate that the location and extent of deep venous thrombosis is not due to a thrombosis in the calf that extends, propagates, and ultimately becomes symptomatic. In their study, 49% of the thromboses occurred in the thigh or popliteal space without calf involvement and therefore would not have propagated from a calf vein thrombosis. Their findings indicate that a thrombosis can occur at any location in the leg, but most commonly occur in the thigh.

COMMENTARY

This is an extremely important and interesting paper since it not only contradicts long beliefs regarding propagation of calf thrombosis but also provides valuable information regarding the location and extent of lower extremity venous thrombi. The paper underscores the value of carefully scanning the entire leg and suggests that examining the opposite leg may also be important since 19% of the thrombi were bilateral.

The importance of age as a contributing factor in patients with DVT is suggested. Those with a more extensive thrombotic process were older than those with isolated single-segment disease. The high proportion of referred patients with DVT and cancer, myocardial infarction, or postoperative state is not surprising. These data stimulate one to ask what methods of thrombosis prophylaxis were used in these patients. Perhaps more prophylaxis is necessary and could be the subject of another study or protocol.

Finally, we are indebted to the authors for a careful and thorough analysis involving the origin and extent of leg thrombi as well as their correlation with a variety of factors including several comorbid conditions. Future serial studies over time in these individuals may not only be interesting but may improve insight into the etiology of the postphlebitic syndrome. 6917b




ANTIPHOSPHOLIPID SYNDROME AND THE SKIN
 Gibson E, Su WP, Pittelkow MR
J Am Acad Dermatol 1997; 36:970-82

ABSTRACT AND COMMENTARY BY:
Mitchel P. Goldman, M.D.
La Jolla, California

The antiphospholipid syndrome is an acquired, multisystem disorder of hypercoagulation which may be primary or secondary to underlying diseases. Serologic markers for the syndrome are the lupis anticoagulant and anticardiolipin antibodies. Clinical features include recurrent thrombotic events (arterial or venous), repeated fetal loss, and thrombocytopenia. Cutaneous manifestations may occur as the first sign of the antiphospholipid syndrome. These include livedo reticularis, necrotizing vasculitis, livedoid vasculitis, thrombophlebitis, cutaneous ulceration and necrosis, erythematous macules, purpura, ecchymoses, painful skin nodules, and subungual splinter hemorrhages. The antiphospholipid syndrome may also be rarely associated with anetoderma, discoid lupus erythematosus, cutaneous T-cell lymphoma, or disorders closely resembling Sneddon or Degos syndromes. Non-inflammatory vascular thrombosis is the most frequent histopathologic feature observed. Prophylaxis and treatment of thrombosis in patients with antiphospholipid syndrome relies principally on anticoagulant and antiplatelet agents.

COMMENTARY

This review provides a concise summary of this syndrome with useful tables and photographs of the cutaneous manifestations. The multiple cutaneous manifestations are well described. An awareness of these manifestations, together with the cutaneous histopathologic features should facilitate early diagnosis and institution of appropriate therapy. 6919b




MINI ABSTRACTS
John J. Bergan, M.D.
Items of Interest Which Have Crossed the Editor's Desk
(Provided for reference purposes and general interest)


Opinions Regarding the Diagnosis and Management of Venous Thromboembolic Disease ACCP Consensus Committee on Pulmonary Embolism
Chest 1996; 109:233-37

This very valuable report comes from the Committee on Pulmonary Embolism of the American College of Chest Physicians. It answers questions regarding the diagnosis and management of acute pulmonary embolization and provides much valuable information.